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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT UNDERGR 'ND STORAGE TANK PROGRAM .E WORKSHEET FACILITY NAME FACILITY CONTACT NAME V-� ( FACILITY ADDRESS SITE PHONE # WITH AREA CODE /> z—i 5 v F -`i4I z - CITY STATE ZIP CODE # OF TANKS AT SITE S+-c� (� �' - CA 6� S 2 �, & APPLICANT BILLING NAME APPLICANT CONTACT NAME Cr�� 1999 APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE (, f's<< t �S t C; �� \� z—,( i Y DS _ Ct l I Z CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: Closure Installation Repair Retrofit S+-c� (� �' - C 1. 6� S 2 �, & ACTIVE FACILITY TANK ID # (s): CLOSURE FEE = $279 / TANK 1999 2000 2001 2002 2003 2004 $500 FEE INCLUDES FACILITY FEE + 1 TANK ($170) X (#tanks) UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR SAMPLING INSPECTION FEE _ $ 93/ HOUR $125 PER TANK AFTER FIRST TANK $ TANK PENALTY ASSESSED TANK SURCHARGE = $15 / TANK $ STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.00/ FACILITY PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID # (s): CLOSURE FEE = $279 / TANK # TANKS X $279 = TEMPORARY CLOSURE Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE = $2791 FACILITY TALLATION PLAN CHECK n Check and Construction I TANK ID # (s) : PLAN CHECK FEE = $744 / FACILITY REPAIR PLAN CHECK TANK ID # (s): TANK RETROFIT REPAIR FEE = $279 / FACILITY (use for monitoring equipment, spill buckets, tank sumps, misc.) PIPING REPAIR FEE = $279 / FACILITY (use for piping, under -dispenser containment, ect.) $ MISCELLANEOUS TRANSFER FEE _ $ 20 $ CONSULTATION FEE _ $ 93/ HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR SAMPLING INSPECTION FEE _ $ 93/ HOUR ALL FEES ARE BASED ON THE $93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. . OFFICE USE ONLY SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED SR EH 23 032 (REVISED 01/22/04)